More and more Americans are flocking to urban areas, leaving small towns for opportunities and adventures in big cities. This sounds natural because it has always been a pop culture trope: boy/girl goes to city to chase dreams, struggles, meets girl/boy and makes it while also learning about the value of small-town morals. But this was really just a trope up until the nineties. Now, it’s a trend in overdrive. Currently, only 15 percent of Americans live in counties with less than 1,000 people per square mile. These eccentrics — and that’s what they are at this point — are often portrayed as healthier or more stable, having opted out of the destabilizing rat race. Surely there’s a smidge of cultural truth to that, but as urbanization increases, rural life has become risky.

Of course, risk is inevitable wherever you go. Adverse urban environments — characterized by economic disadvantage, crime, and segregation — are associated with chronic psychological and physiological stress. There’s a reason for this: Cities expose their inhabitants to stressors, like polluted air, crowds, and the pathogens with which crowds pollute the air. These factors raise anxiety, which is no good for anyone. There’s also this: People who sit all day at work, grab takeout, and then go drinking don’t always have the best health outcomes.

But people in rural areas remain worse off than urbanites when it comes to their health. The issue, research shows, isn’t that people in the country get sick more often than people in the city. The issue is what happens when people get sick.

In a 2014 study, researchers compared the frequency of suicides, homicides, and traffic fatalities in urban and rural Brazil and America. They found that while there was a higher level of violence in urban areas, which they plausibly linked to population, the suicide rate in cities was disproportionately low. The researchers concluded this was likely because cities host supportive social networks. A separate study of 66,595 American youths seemed to confirm that conclusion, finding that, between 1996 and 2010, children and young adults in rural areas committed suicide at twice the rate of their urbanized peers.

Wind turbines rise up above farmland on the outskirts of the Wisconsin state capital.
Wind turbines rise up above farmland on the outskirts of the Wisconsin state capital.

“We were not surprised by the higher rates in rural areas,” study author Cynthia Fontanella told Medical Daily. “What was surprising is that the gap/disparity is widening over time. As for the advances in technology, although more technology is available, the ‘playing field’ is not necessarily level due to differences in the culture surrounding rural life.”

Fontanella and her team make the case that rural residents may suffer because they face a stigma that those who live in cities do not. They also write that people who live in rural areas often have less access to effective counseling and medical care. And that often means that there aren’t adults actively advocating against bad decisions in a credible way.

“Urban and rural children differ in their demographic characteristics, which, in combination with geographic factors, can affect their health status and access to health care,” reads a 2014 U.S. Department of Health and Services report. “For instance, children living in rural areas are more vulnerable to death from injuries, are more likely to use tobacco and other substances, and are more likely to be obese than their urban counterparts.”

Trey Dodds and Cole Hoacek get settled in for the start of a movie at the Starlite Drive-In Theater in Neligh, Nebraska.
Trey Dodds and Cole Hoacek get settled in for the start of a movie at the Starlite Drive-In Theater in Neligh, Nebraska.

Unfortunately, this means that the healthy farmer, a cultural archetype, is a false flag. As of 2003, one-third of adults in rural areas, compared to less than one-quarter of adults in urban areas, believed that their health hindered them from being successful in activities like paid work, school, and housework. Approximately 14 percent reported they had a physical limitation that prohibited them from relatively simple activities like walking three blocks or lifting ten pounds, compared to the nine percent or urban adults who felt the same.

Studies also reveal that city-dwellers may be indulgent, but country folk often take bigger risks. A larger proportion of rural residents drink an average of five or more alcoholic drinks a day and are more likely to be overweight, obese, and less physically active. According to the National Rural Health Foundation, 40 percent of rural 12th graders self-reported drinking alcohol compared to the 25 percent of their urban peers. Additionally, rural 8th-grade students were twice as likely to smoke cigarettes.

And when healthcare is hard to come by, poor health persists because of the lack of access to medical providers. According to Georgetown University’s “Rural and Urban Health Report,” 25 percent of the American population and 10 percent of doctors live in “rural” areas. Dentists self-sort similarly: There are about 29 dentists to every 100,000 residents in rural areas, compared to 61 dentists to every 100,000 residents in cities.

However, while rural residents bear the brunt of medical problems now, public health experts are steadily raising their concerns about the problem zones of the future: megacities. Currently, 54 percent of the world’s population lives in urban areas; that number is expected to grow to 66 percent by 2050. The World Health Organization warns that cities, as populations rise, will further become concentrated risks and hazards for health. In a 2010 report, the WHO writes:

“When large numbers of people are linked together in space and connected by shared services, the consequences of adverse events — like the contamination of the food or water supply, high levels of air or noise pollution, a chemical spill, a disease outbreak or natural disaster — are vastly amplified.”

Migrant workers harvest watermelon from an irrigated farm field near Vincennes, Indiana.
Migrant workers harvest watermelon from an irrigated farm field near Vincennes, Indiana. 

This concern with cities is less of what it is about cities that make people ill, and more so how difficult it is to manage disease in cities. Infectious diseases, like tuberculosis, AIDS, and syphilis have a history of infecting at higher rates in cities compared to less populated regions. The goal for public health officials now is to build a plan for when the inevitable happens.

Who’s healthier — urban or rural folk? Today, with more access to medical services and a more active lifestyle, it’s the urbanites who come out ahead. That will likely change, but probably not very soon.

Photos via Getty Images / Scott Olson, Getty Images / Mario Tama

Sarah is a writer based in Brooklyn. She has previously written for The New Republic, Pacific Standard, and McSweeney's Internet Tendency. She likes cheese especially when paired with a full-bodied joke.